Healthcare Dive interviewed a series of telehealth executives for our project examining the state of healthcare six months into the COVID-19 public health emergency.
Here, we provide fuller responses to some of the most pressing questions facing the sector today from leadership at three of the country's biggest telehealth providers: Roy Schoenberg, president and CEO of Amwell; David Sides; COO of Teladoc; and Robin Glass, president of Doctor on Demand.
Responses have been edited for brevity and clarity.
HEALTHCARE DIVE: How has volume shifted from January to now?
ROY SCHOENBERG: Wow, how the world's changed. It's truly unbelievable. In some ways, COVID accelerated something we knew was coming anyway. We've always been in a position where we said healthcare can be delivered virtually. A lot of people for many years said healthcare was different. But the reality is just like in retail, in banking, in entertainment, in every other industry, there is a place for interactions over digital channels as well.
The volumes of telehealth during COVID have catapulted twentyfold, thirtyfold, fortyfold — many, many orders of magnitude. They have come down a little bit, because things are beginning to relax. But they're still orders of magnitude above where they used to be.
Urgent care volume went up in a significant way, but as physical alternatives open up that volume is beginning to go down. It will continue to go down if we see more relaxed social distancing, more offices opening — that's realistically what's going to happen.
Physicians in the community have turned to telehealth as well in a more simplified fashion, using us or Zoom or Facetime, to ensure they can do justice to their patients. Those mom and pop physician practices — those are also beginning to go down because they can open their offices. And that's going to continue to go down.
DAVID SIDES: We had over 20,000 visits per day in March. That's much higher than we'd ever seen, even a few weeks before. That mitigated somewhat in May and June, with a surge in some states that was reflected in our data. Things have picked back up, but not at the same levels that they were.
Driving the visits was a need for access. If you're in lockdown at home, there really wasn't any other access and many physician offices were closed. It's been a catalyst in consumer adoption. Sixty percent of visits were new customers for us — that's a really high usage of people for the first time, and that's a reason it'll persist.
Mental health seems to have stayed stronger than general medicine. COVID seems to have slowed other infectious diseases — we're not in airports, we're not in school, we're not gathering together. But for COVID, there's no vaccine, no cure, and a lot of stress on people from an economic standpoint. So we've seen a continued rise on the mental health side.
ROBIN GLASS: Prior to the pandemic, the single largest barrier besides regulatory ones was just awareness. What we see is, the minute a patient uses virtual care they find that they love it, and they come back again and again. Seventy percent of our business is returning.
One of the things that the pandemic's done — and it's obviously been a horrific thing for our country and the world — but it's definitely helped us with that awareness barrier.
We started anticipating and preparing for the pandemic in mid- to late February. I can recall, it was Feb. 22 or 23, and we were sitting down with our board and realized this was coming like a freight train at us and we needed to get ready.
Sure enough, come early March, we started to see our volume increase really substantially. There was a period in there that felt a little bit like a tidal wave. There were a few pretty intense weeks recruiting physicians for our platform and getting our supply to match up with demand. We onboarded 400 more doctors starting in late March through April, more than doubling the physicians practicing on our platform.
Volume continued to increase through April. We didn't see leveling out until late May. There's been just a little bit of waning on the medicine side of the practice — it started to come down, but never returned to normal amounts compared to 2019. Behavioral health volumes never slowed down. We've seen an ongoing upward trajectory of those throughout.
Over the past few weeks, we're seeing volume tick back up, reflecting what we’re broadly seeing across the country. We're definitely seeing that reflected in our visit volume.
What regulatory changes have been most helpful? Which do you think are likeliest to remain post-national emergency?
SCHOENBERG: The part that I would expect to be the most meaningful is that Congress allowed the secretary of HHS to determine exemption rules for the reimbursement of telehealth. Allowing HHS to continue to be in that position, even if the emergency rules are lifted, I think is going to be the most fundamental change. It allows HHS and CMS to completely revisit their view on paying for telehealth services.
If that is not granted, the moment the emergency rule is lifted all Medicare payment for telehealth disappears. It would have devastating consequences for the American people.
HIPAA is probably going to come back, and that's the right thing to do. Making sure clinical information is utilized appropriately needs to exist, and be taken care of.
I think state licensure has been given a run for its money during COVID, especially in states that were overwhelmed with patients that didn't have enough clinical supply, and opened the door for good quality physicians from the rest of the country to pull together and help. That level of comradery where the country came together and load balanced its resources — that was heard loud and clear in Washington.
We're going to being to see over the next couple years more regimented, prescribed ways in which state licensure is going to be lifted. But it's not going to be discarded completely because it does serve a purpose. It's a way to keep physicians accountable to their medical boards. But state licensure compacts are going to be significantly accelerated, or morph into a uniform federal initiative that under certain circumstances allows physicians to care for patients outside their state.
SIDES: The regulatory changes, while helpful, I don't think will be long-lived. I don't think anyone wants to relax the HIPAA rules long term, when you see data privacy problems, people getting into other people's videos.
Multistate licensure — I think the medical boards will pull that back over time as well. It may have helped in the short term, but long-term I expect it won't. The multistate licensure was a way to draw in capacity from other states to help with COVID. I don’t think it'll persist but I think it was a good response.
Reimbursement in Medicare I think will persist. Almost 50% of docs have used telemedicine now, and they're thinking about other ways they can use it.
GLASS: Some leniency that started with the federal government around state licensure — that allowed us more flexibility to see patients across state lines. Usually, getting physicians licensed in all 50 states is a multi-month process. I hope states consider keeping this, realizing that's not something that's necessary moving forward.
The Medicare population, we've always served in a small capacity through direct-to-consumer, and we have some Medicare Advantage plans. But the change to serve a larger swath of beneficiaries in Part B was really exciting for us. We credentialed all our providers in Medicare and launched for that population in May.
It’s a huge market, and it's not necessarily the population that's going to be the most likely to adopt telehealth just based on comfort with technology and some other factors. But we've been really heartened by our progress so far.
Do you think virtual visits should be reimbursed at in-person rates? What do you think is the likelihood of achieving parity?
SCHOENBERG: When you buy a product online and you buy a product in a shop, in the early days of retail they were priced differently and that made sense, because the operation of a shop was actually a lot more expensive than sending you a box. Today, we've arrived at the point when, if you buy a product in the shop or online, they have to be priced the same. That's the reality.
While buying products off a shelf and getting healthcare services are not the same, we have to understand if clinicians believe the care they give to a patient is equivalent digitally and physically and we rely on them to make that judgement call, if they choose to engage a digital channel to care for their patients and say it's the same, we have to accept it's the same, and reimburse the same. It's the same product, so to speak, though we tend to not think of healthcare as a product.
SIDES: I think it'll reduce. It won't be at the same rate as an in-person rate. There are reasonable arguments for that: you don't have the overhead of a physical place to cover. You wouldn't have to pay however much that price is. And the convenience factor also is something where people may be willing to take slightly less compensation — I'm not commuting an hour to get there. You're getting that savings as well. But it'll probably mitigate. The costs should be slightly less.
GLASS: Payers, and in particular the federal government, are realizing the importance of providing robust clinical options that are virtual in nature. We're supportive of what they're doing in parity right now.
But over time, it’s very important for policymakers and other purchasers of healthcare to be sure they're getting the same thing in terms of quality of care in a virtual setting. I don't think all virtual care is created equal — some are more robust than others, and have necessary privacy implications.
I anticipate more scrutiny, and in time certain standards, that have to be met that nobody can account for right now. Over time, we're going to have to think about things like, is a quick phone call the same thing as a face-to-face video visit?
What do you think is next for the industry and for your company?
SCHOENBERG: I think the biggest change is that the effort to convince people around the human and industrial value of telehealth is behind us. I don't think anybody contests that anymore. Now the question is going to be, where first? How much?
The most interesting volume, at least half of our business, is the way we work with health systems, using telehealth to restore patient encounters. Most of the care they do is with chronic patients and they moved a lot of that care to telehealth. Now that COVID is going away, it's hard for that patient population to go into the office every week. The fact that you can deliver good care for them at home, from a humanitarian standpoint, makes it that much easier for them than if you make them take a bus and queue somewhere in a hospital.
I think that's where the biggest change is going to be. The industry's going to morph to create new products that are oriented around managing those patients at home.
It’s going to be a whole new reality in how you manage that patient population that nobody in good conscience should take away from them. Saying now to that patient, 'We've changed the rules and COVID is gone, now we're going to throw the red tape at you' — I don't know how people are going to be able to say that.
There are generations when nothing happens. There are decades when nothing happens. And there are weeks when decades happen. And that's exactly what we've gone through.
There's still a long ways to go. But that's part of the fun.
SIDES: For providers, it's just really been a catalyst and moved things forward. Primary care physicians are doing virtual visits with people with chronic conditions, because there's no access. Even now, you may not want to bring that person in because they're higher risk.
You have telestroke sorts of things. For example, many hospitals don't have a neurologist on staff — you have to be a large facility to have that all the time — now hospitals can have a physician see the patient, use the EMR and talk to a neurologist in another location, and get the treatment started, without having to have someone staffed there 20 hours a day.
People are now just getting accustomed to it, but they may start to demand it. Why should someone in a rural area, in an underserved inner city — why shouldn't they have the same level of care? I think telehealth can be that great equalizer.
GLASS: The trick here is we've all been conditioned to consume healthcare in this challenging way. It's not that great of an experience. Now we're providing a version of care that is very much centered around the patient: eye-to-eye contact with a physician from the comfort of your couch.
I think virtual care will never be the same. It was an underappreciated aspect of the care ecosystem up until now. And it’s gotten its moment in the sun. And it's going to become a really strategic part of how healthcare payers and purchasers think about their overall healthcare offerings.
What I hope to see is deeper and deeper integration across the system, so we can have data flows so patients can get care virtually, and in-person. We want less fragmentation across the healthcare system. The ability to share data and create a more unified patient experience — there's a real opportunity for that.